What is needed to sustain comprehensive medication management? One health plan’s perspectives

Implementation of comprehensive medication management (CMM) in the community pharmacy setting remains sporadic despite its prevalence in other pharmacy contexts. One health plan has been investing in CMM since 2010. Their experience and perceptions in the payer-provider partnership could offer unique insights into the sustainability of CMM in community pharmacy. As part of a broader academic-payer-provider partnership, perceptions of CMM sustainability were explored with key stakeholders in the health plan through a semistructured group interview. Five themes emerged: (1) distinction between CMM and other patient care opportunities, (2) building a CMM program that delivers value requires an investment in network development, (3) payment design influences sustainability, (4) lack of push from community pharmacies to pay for CMM, and (5) the importance of an ongoing facilitated learning and action collaborative. Given previously demonstrated positive return-on-investment, CMM in community pharmacies shows promise for being a sustainable practice model. However, increased reach and performance of networks, as well as number of payers in the market, will be critical to scaling CMM in the community pharmacy setting.

The practice of comprehensive medication management (CMM), first defined as pharmaceutical care, was introduced in 1990. 1 However, more than 30 years later, CMM delivery across community pharmacies remains sporadic. CMM is a standard of care in which the pharmacist reviews every medication a patient is taking to ensure each one is appropriate, is effective for the condition being treated, and is safe given other comorbidities and medications as well as assessing the patient's medication adherence. If any medication therapy problems are identified during this process, the pharmacist develops an individualized care plan What is needed to sustain comprehensive medication management? One health plan's perspectives Deborah L Pestka, PharmD, PhD; Carrie M Blanchard, PharmD, MPH; Todd D Sorensen, PharmD, FCCP ABSTRACT Implementation of comprehensive medication management (CMM) in the community pharmacy setting remains sporadic despite its prevalence in other pharmacy contexts. One health plan has been investing in CMM since 2010. Their experience and perceptions in the payer-provider partnership could offer unique insights into the sustainability of CMM in community pharmacy. As part of a broader academic-payer-provider partnership, perceptions of CMM sustainability were explored with key stakeholders in the health plan through a semistructured group interview. Five themes emerged: (1) distinction between CMM and other patient care opportunities, (2) building a CMM program that delivers value requires an investment in network development, (3) payment design influences sustainability, (4) lack of push from community pharmacies to pay for CMM, and (5) the importance of an ongoing facilitated learning and action collaborative. Given previously demonstrated positive return-oninvestment, CMM in community pharmacies shows promise for being a sustainable practice model. However, increased reach and performance of networks, as well as number of payers in the market, will be critical to scaling CMM in the community pharmacy setting.

Plain language summary
Few community pharmacies provide patient care services, such as comprehensive medication management (CMM). One health plan in Minnesota, HealthPartners, has been supporting pharmacies in their pursuits to offer CMM for more than a decade. This viewpoint outlines their thoughts on what is necessary to sustain CMM in the community pharmacy setting. They stressed the importance of differentiating CMM from other services, providing support for pharmacies doing CMM, and the influence payment models have on sustainability of CMM.

Implications for managed care pharmacy
This viewpoint shares key insights from a health plan with years of experience on what is needed to support and sustain the delivery of comprehensive medication management services within community pharmacies. The viewpoint highlights the need for more payers to cover comprehensive medication management for it to be sustainable as well as the additional pieces that must be considered to ensure consistency and quality of the service to distinguish it from other patient care opportunities.
in collaboration with the patient and their care team, and the pharmacist continues to follow up with the patient to ensure that they are meeting their health care goals. 2 Given the high costs associated with medication-related morbidity and mortality, 3 CMM is more important than ever.
When implementing any program or service, a key component to consider is sustainability. 4 Sustainability is the extent to which a program, such as CMM, is maintained or institutionalized within an organization's ongoing, stable operations. 5 Within the field of implementation science, sustainability has been identified as a key area of determining implementation success. Often health care entities focus on service outcomes, such as efficiency, effectiveness, and patient-centeredness; however, implementation outcomes are important to consider to determine if there are issues with the model itself vs the manner in which it is implemented. 5 Cost has frequently been cited as a barrier to implementing medication management services. 6 Therefore, it is important to understand the insights and perspectives of sustainability of CMM from the payment side of the payer-provider relationship. For that reason, we sought to understand the perspectives of a health plan with years of experience covering CMM on the sustainability of CMM in community pharmacies. The goal was to understand their perspectives as an individual plan, as well as their thoughts on what is needed generally across all payers to sustain CMM services in the marketplace.

PARTNERS IN EXCELLENCE PROGRAM
In 2010, a health plan in Minnesota, HealthPartners, created a payment model for CMM for its commercially insured members. Based on internal evaluations demonstrating a positive return-on-investment from this service, the program was expanded in 2015 to include a performance-based component called Partners in Excellence (PIE). Community pharmacies and health systems participating in PIE are rewarded by HealthPartners if they improve select health outcome measures and engage a certain proportion of attributed HealthPartners beneficiaries in CMM. HealthPartners provides participating organizations with quarterly registries of patients at risk for medication-related problems based on available medical and prescription claims data. However, organizations may provide CMM to any patient they feel may benefit from the service. HealthPartners requires that pharmacists perform CMM in alignment with the Patient Care Process for CMM, 7 and compensation for CMM is provided through both encounter-based payment (ie, fee-for-service) and bonus payments based on annual performance.

SLICE OF PIE
Previously, community pharmacy engagement in CMM, and thus the PIE program, had been minimal. To build community pharmacy engagement in the PIE program, facilitate pharmacies' achievement of the patient and clinical metrics of the PIE program, and develop a payer-provider partnership, Slice of PIE was initiated in September 2019. Slice of PIE was an 18-month implementation and research initiative providing regular implementation coaching, pacing events, and a collaborative learning environment for participating pharmacies. Coaching consisted of monthly meetings between pharmacies and an implementation coach where they would provide leadership guidance and help teams overcome barriers. In addition, there were regularly occurring webinars in which participating pharmacies could share experiences and learn from one another. All pharmacies within the HealthPartners CMM network were invited to participate in Slice of PIE, and of those, 12 organizations signed up to participate. Of these organizations, some had previously participated in PIE, but several were new to the program.

Understanding HealthPartners' Views on CMM Sustainability
To determine HealthPartners' perspective on sustainability, 3 key stakeholders from the HealthPartners' PIE program were invited to participate in a semistructured group interview with 3 Slice of PIE study investigators (DLP, CMB, and TDS). One investigator (DLP) led the discussion using a discussion guide (Supplementary Material 1, available in online article), while the other 2 investigators took notes and asked follow-up questions. The discussion guide was emailed to the stakeholders ahead of time to allow them time to reflect on the questions. The group interview occurred via Zoom in February 2021, near the end of the 18-month Slice of PIE initiative. The conversation was recorded, transcribed, and reviewed by the investigators for key takeaways.

Themes From the Conversation
There were several key themes that emerged in the discussion with HealthPartners. These themes are consistent with existing sustainability frameworks that stress the importance and interplay of the intervention, implementation strategies, and setting on sustainability. 8,9 Themes are presented and described below.
this without the support that they had. As a health plan, we don't have the resources to provide to them to be able to do that." Health plan investment in infrastructure development was mentioned as being necessary in 2 key areas: building a practice and adhering to CMM consistency and quality.
Building a Practice. HealthPartners has invested a significant amount of time and resources to develop their CMM network. During the discussion, they reflected on their efforts so far and what they feel is needed to build a network of community pharmacies delivering CMM. HealthPartners stakeholders discussed that health systems may also require assistance with providing CMM; however, because community pharmacies are not used to billing medical claims, getting community pharmacies to a place where they understand and know how to correctly apply International Classification of Diseases, Tenth Revision, Clinical Modification codes requires a great deal of support. It was also brought up that providing CMM was a culture shift for many community pharmacies and that some still have work to do in order to be sustainable in the network. A contextual component that was brought up affecting consistency and quality, as well as sustainability of CMM, was that during times of high demand for immunizations (ie, COVID-19 and influenza), some pharmacies prioritize delivering immunizations over CMM. These seasonal variations in when CMM is performed create fluxes in consistency and make sustainability difficult because they affect longitudinal relationships with patients, follow-ups, and the ability to connect with new patients. It was also commented that because CMM requires more time, a

DISTINCTION BETWEEN CMM AND OTHER PATIENT CARE OPPORTUNITIES
Although not directly tied to sustainability, an important point that came up early in the conversation was the difference between CMM and other patient care initiatives that may be available to community pharmacies. For example, other vendors provide compensation for services delivered by pharmacists if they provide targeted interventions, such as increasing statin use in patients with diabetes, increasing adherence to certain medications, and moving patients from 30-day fills to 90-day, among others. It was mentioned that this is now what many pharmacists are used to, which is very different from the comprehensive assessment and follow up HealthPartners expects from pharmacists. In addition, although other programs are more directive in who pharmacists should reach out to, HealthPartners encourages the pharmacies they contract with to also selfidentify patients.

BUILDING A CMM PROGRAM THAT DELIVERS VALUE REQUIRES AN INVESTMENT IN NETWORK DEVELOPMENT
A key learning around sustainability that came up in the discussion was the need for health plan infrastructure to support community pharmacies providing CMM and the value of the implementation supports provided through Slice of PIE.

What This Means for the Profession and Managed Care Pharmacy
This viewpoint represents the perspective of one health plan. However, HealthPartners has been engaged in payment programs for CMM for 15 years, has engaged in payment programs across all 3 books of business (Medicare, Medicaid, and commercial insurance), has evolved administrative processes (claims and clinical documentation submission) in collaboration with its provider network, and has conducted multiple internal return-on-investment (ROI) analyses. It is a health plan that has notable experience that allows for an informed perspective on service delivery, payment program structure, and producing net positive value. Although other health plans in other regions may have different viewpoints, we posit that HealthPartners' perspective is as well informed as any other health plan on the potential impact of CMM to a payer and the structural elements required to produce consistent returns, ie, produce sustainability. Internal evaluations of economic return from CMM have demonstrated up to a 12:1 ROI for CMM delivered to its highest-utilizing, high-risk populations of beneficiaries. Because of the expectations for CMM combined with a service delivery auditing process, there is a confidence in the nature of the intervention that has produced this return. Unlike many other evaluations that have not demonstrated a net positive value for medication management programs, [11][12][13] the intervention across the HealthPartners provider network has a degree of fidelity for a well-defined clinical intervention. challenge of sustainability is that management may not be willing to give up the "easy dollars" associated with delivering immunizations for the "harder dollars" that come with delivering CMM.

PAYMENT DESIGN INFLUENCES SUSTAINABILITY
A key piece of CMM sustainability is payment, and the HealthPartners stakeholders discussed that there are a number of reasons that may motivate payment for CMM. According to one of the stakeholders, payers "pay because they have to, they pay because they think it's valuable…and they pay because their competitors do it and they feel like they have to do it." There are also a number of ways to pay for CMM delivery (eg, fee-for-service,

LACK OF PUSH FROM COMMUNITY PHARMACIES TO PAY FOR CMM
Discussing payment further, another theme that emerged was the limited opportunities community pharmacies have to advocate for payment of CMM. Health systems, it was mentioned, frequently have contracting discussions in which they advocate for payment for CMM, whereas community pharmacies may not have these same opportunities. An important point that was also brought up is that paying for CMM in the community setting may be a catch-22 because you need a payer to develop a CMM network, but you need a network to entice payers.

IMPORTANCE OF AN ONGOING FACILITATED LEARNING AND ACTION COLLABORATIVE
According to HealthPartners stakeholders, one of the most beneficial things that came from Slice of PIE was the collaborative learning environment. As one stakeholder said, "Slice of PIE, I think, has really built connections between the groups…which I feel is really important because they couldn't have gotten as far as they did." multiple payers in a market to offer similar payment opportunities in order to truly produce sustainability. A single payer recognizing a positive return does not produce enough of a business opportunity among a community of practitioners to support their full investment in service adoption and delivery.

Conclusion
Often, when health care leaders invoke the term "payer-provider partnerships," the focus is on shared economic risk associated with a beneficiary group. From this work, we call on both health plan and health care delivery leaders to recognize that in order to produce substantial value from medication management services, these partnerships need to extend well beyond the shared risk construct. With health plans standing to gain significantly from services that impact total cost of care and other relevant clinic and economic metrics, this evaluation suggests that it is incumbent on health plan leaders to look critically at the implementation strategies that ultimately produce a net ROI and invest in the those structures that will drive success, such as implementation supports, population management tools, efficient administrative processes, and open and active communication channels. Furthermore, ensuring that development of these structures hold a degree of consistency between health plans in a region is critical for success of the payer-provider community. Thus, expanding communities of learning not only between individual plans and their provider networks but also between health plans will create an environment in which provider engagement will grow. The lessons learned presented here and applied across health plans can create a "rising tide lifts all boats" opportunity.
It should be noted that prior to the Slice of PIE initiative, most claims submitted by members of the HealthPartners CMM Network were from pharmacists practicing in health systems. Interviewees acknowledged some of the unique challenges encountered by pharmacists providing CMM in the community pharmacy setting. Those challenges primarily exist with the setting and infrastructure and not with regulatory limitations to the setting. In Minnesota, all pharmacists can establish collaborative practice agreements with medical providers and all are eligible for payment for CMM delivered to Medicaid beneficiaries. A growing list of health plans in Minnesota are incorporating CMM into their commercial program offerings; provider eligibility is the same for pharmacy providers in health systems or community pharmacies. Despite an open playing field from a regulatory standpoint, other factors may affect the ability of CMM to deliver an ROI equally between the 2 settings. At the time of writing this paper, this evaluation of ROI by health systembased versus community pharmacy practices is pending.
Despite 15 years of experience, program leaders at HealthPartners have indicated that they are continuing to learn what is required to optimize the program and establish long-term sustainability. As it relates to this interview and Slice of PIE, a key finding is the need to invest in the scale and performance of its network. A number of lessons learned regarding strategies to create greater engagement from community pharmacists and supporting their adoption of a clinical service model that has produced positive outcomes in other health care settings are shared here. However, although Slice of PIE has resulted in greater engagement from community pharmacists, it is also recognized that there is a need for